RASHID sold his kidney six weeks ago and gave all his ‘earnings’ from it to the zamindar. He still owes him Rs300,000.
About 200 kilometres from Rawalpindi is the town of Kot Momin. Its proximity to the international standard motorway that connects Islamabad with Lahore throws into relief the vast chasm between the modern and the medieval in certain parts of Pakistan.
Lush fields of corn and rice stretch across the landscape, as do orchards of ImaltaI. This is Pakistan’s ‘citrus basket’ and the crop earned Pakistan around $365 million in foreign exchange last year. Yet there is desperate poverty here, among the bonded labour that toils on the farms, at brick kilns and in the homes of the landowners. These modern-day slaves work to pay off crushing debts in an opaque system of usury that ensures generations-long servitude. Such deprivation is the natural hunting ground of ‘agents’ — affiliated with hospitals that conduct illegal transplants — seeking people desperate enough to sell their organs.
A study cited at a Harvard conference in 2008 found that 70 per cent of donors in Pakistan were bonded labourers; 90pc were illiterate; 88pc had no improvement in economic status from the donation; and 98pc reported a subsequent decline in health, including chronic pain from large incisions.
Several villages in the Kot Momin area had become notorious for vended kidneys before the organ transplantation law was passed. According to residents, the media attention in the mid to late 2000s led to agents looking for donors in other similarly deprived parts of the country. One of the locals, Mohammed Zafar said, “There was an agent here named Khalid who had arranged for scores of people to sell their kidneys, but he ran away after an arrest warrant was issued for him,” said.
However, bonded labourers willing to sell their kidneys can still be found here, as can agents who continue to scout for them. “Before, one would get around 60,000 for selling a kidney. It’s gone up since then,” said a resident. According to locals, the agent of the moment is Afzal, who visits from Rawalpindi, armed with a portable kit for basic blood sampling.
Halima, a young mother of seven, sold her kidney eight months ago for Rs180,000. Her children have never been to school: the government school which offers free education is too far. Her family owes Rs400,000 to the zamindar on whose fields her husband works seven days a week. “First Afzal [the agent] took me to court where I had to put my thumb impression on some documents. The operation took place at Rawalpindi’s IdilI hospital [as the facility is known in local parlance],” said Halima. “They kept me there for four days, and discharged me with some painkillers. The doctor’s name was Khalid.” (Unknown to her, she was in the third month of her pregnancy at the time: no one at the hospital informed her of the fact.)
According to a local journalist, donors are sometimes made to submit affidavits claiming they are having their failing kidneys removed. “It’s all very clandestine. The police are not interested in looking into it, neither is the administration.”
Halima was fortunate her incision healed well. When some donors develop complications, such as incisions becoming septic, sutures tearing, etc they have to bear their own medical expenses. The tehsil hospital, said villagers, offers substandard care, and donors in need of medical attention opt for private ‘doctors’ — in reality, smalltime compounders with hole-in-the-wall ‘medical practices’.
Twenty-seven-year-old Rashid, who suffers from night blindness, sold his kidney six weeks ago. Relatives said he was in such despair over the debt he owed his landlord that he had been contemplating suicide. But even selling his kidney did not appear to have brought him relief. Hunched on a charpoy, he seemed weighed down with misery. Occasionally wiping his rheumy eyes with a cloth, he did not look up while speaking. The eight-inch scar from his surgery had not quite healed, and he grimaced with pain as he lifted his shirt to show it. He had not yet been able to resume working in the field.
According to Rashid, the agent Afzal handed him over to another agent named Cheema, who took him for his initial test to a laboratory at Rawalpindi’s Pir Wadhai Mor. The transplant took place in the evening a week later at a hospital in Rawalpindi. “A doctor named Zahid operated on me,” he said. There, he came across another donor, who was from Sheikhupura. Rashid was discharged after three days with two painkillers, no prescription and no advice on any precautions he needed to take in the post-operative period.
“Afzal had promised me Rs250,000 but gave me only Rs150,000.” Asked what he did with the money, Rashid said: “I handed it over to the zamindar.” Despite knowing at what cost he had obtained that cash, the landlord pocketed the entire amount. Rashid still owes him Rs300,000. Until he pays that off, he and his family remain indentured.
Ejaz, a bonded labourer working at a kiln in Lahore’s Batapur area, sold his kidney 18 months ago. “I wanted to free myself of debt bondage, and when I came across someone who told me that I could sell my kidney, it seemed like a good idea,” said Ejaz. “So I went to [a hospital in Lahore] and had it done. The buyer was an Arab, and the hospital paid me Rs200,000.”
He soon discovered that selling his kidney was simpler than extricating himself from debt bondage. The brick kiln owner took the money Ejaz had ‘earned’ for his kidney but informed him there was still Rs.400,000 outstanding against him. Ejaz remains at the kiln to this day.
Local recipients of vended kidneys
Dawood Waheed, 47, was deeply dejected after his consultation with a urologist in a Rawalpindi hospital early last year. The doctor had told him his wife was not a match and he had to find another related donor for a transplant. But Mr Waheed had no hope left. “One brother suffers from hepatitis C, another has himself had a transplant and the third had refused to give his kidney.”
In the foyer, he was approached by one of the hospital’s employees who told him there was someone outside who could help him. When he stepped out of the gate, a man seated in a taxi beckoned to him and told him he could get him a kidney. The entire process, from that meeting to the transplant in April 2015, took three months and cost him around Rs.2m, which he managed to collect with help from relatives. That amount included Rs500,000 he paid to the man who obtained a donor for him.
When he went back to the same urologist after having agreed to purchase a kidney, the doctor did not ask him anything about the donor. “I wasn’t surprised. They’re all mixed up in this. Their lower staff does all the groundwork,” said Mr Waheed. He has no idea who his donor was.
Samir Ahmed, who works at a medical facility in Karachi, had his transplant done one and a half years ago at a Rawalpindi ‘kidney centre’. He suffers from a congenital kidney disorder that renders his family unsuitable as donors. “The hospital said if they arranged a donor for me, the cost would go up from Rs.1m — which they would have charged had I brought a donor myself — to Rs1.7m.”
After his transplant, Dr Ahmed stayed at the hospital for a week. “The place was full. There were lots of foreigners too. Close to my room — there were between 15 and 20 rooms, all private — there was a Saudi, a Libyan and a Bahraini.”
According to him, a lot of documentation had to be completed before the transplant including stamped affidavits to show he had no related donor. That was handled by his brother and his wife, given Dr Ahmed’s critical condition at the time. However he added, “They definitely must have had them sign documents saying they weren’t giving monetary compensation to the donor, whom we never saw.” Did he believe the donor was paid? “Of course. 100 per cent.”
Aiding and abetting a megabucks racket
“Having a law on the books and not implementing it has done more harm than good,” said Dr Saeed Akhtar, who is professor of urology and director of transplant surgery at Shifa Hospital in Islamabad as well as president of the Transplantation Society of Pakistan. “The quality of transplants has gone down, while the cost has gone up. From Rs500,000 to 600,000, it now costs Rs1.5 to 2m. After all, they have to cover all the illegalities.”
The impunity with which the racket is carried out is no secret in the community of kidney specialists, both local and international.
An email dated April 21, 2016, from American transplant surgeon Dr Francis Delmonico, a world-renowned transplantation expert and executive director of the Declaration of Istanbul Custodian Group in 2015 — an international initiative to address organ trafficking, transplant tourism and commercialism — was scathing in its condemnation.
Referring to a 60-year-old woman who had become “acutely ill” after returning home to Vancouver after a transplant in Pakistan, he wrote: “…she had every expectation that she could buy a kidney in Pindi. Because that is the track record for Rawalpindi — everybody knows it, including the Pakistani government.”
However, the Punjab police appears unaware of the scale of the problem. “This is frankly not an issue that is on our radar,” said Dr Haider Ashraf, DIG Operations Lahore. “Moreover, we can only look into a case on the basis of a complaint. That’s not happening, not even on the part of the health authorities.”
According to police, although 63 people were arrested between 2013 and 2016 in Lahore district on suspicion of involvement in organ trade, only two cases are currently being investigated, one from 2014 and another that was registered this year. As per police records, only 12 instances of illegal organ transplants have occurred since 2013 till date.
The fact is that those involved in this business are well-connected individuals who consider themselves above the law. In 2010, a HOTA enquiry team — there was only one HOTA at the time — accompanied by police personnel, visited Al-Sayed Hospital in Rawalpindi on account of repeated claims that doctors at the facility, which is owned by a retired colonel, carried out transplants using vended kidneys. However, members of the team found themselves stonewalled. Hospital staff told them their computer system was down so they could not share details of their transplant cases. When asked for hard copies, they said they didn’t keep any. “Then there were six or seven big operating theatres on the premises but strangely, no operations were being performed there although we went in the daytime,” said a former member of the team. “The people there said operations take place in the evening, which was very odd.” Despite recording their findings in a report to the health ministry, no action was taken.
Various organs of the state — including the health bureaucracy, local government, police, etc —all have a price for colluding in the racket. An Islamabad-based urologist narrated an incident that took place a week ago. “My colleague in Pindi was approached by what was apparently a middleman offering Rs1.6m ‘packages’ to do unrelated living donor transplants, with the proceeds to be divided between the doctor, police, HOTA, and the donor. ” Not only that, the man said he would also have FRCs — Family Registration Certificates issued by the National Database Regulatory Authority that show an individual’s family tree — prepared accordingly to show donors as being related to the prospective recipients.
A urologist at a clinic in Islamabad’s Blue Area stated in the presence of this reporter that it was possible to carry out a non-related transplant and that his nephrologist would line up everything, including the permission from HOTA.
Speaking with IDawnI, Dr Faisal Masood of the Punjab HOTA said: “We don’t allow unrelated transplants. I interview the donor and recipient in each and every transplant case to ensure there is no duress or money involved.” However, according to him, the inspection team makes scheduled, not surprise visits, and checks only “technical” matters. When asked if Punjab HOTA had taken any action against any medical facility for carrying out illegal transplants, he said with considerable vehemence that they could only do so if a complainant came forward “with evidence” and laid the blame squarely at the door of the police who he said were bribed to keep quiet.
When asked whether Punjab HOTA was planning to take any action against hospitals against whom complaints had been received, he said that three hospitals, including Al-Sayed in Rawalpindi, and Badar and Genex in Lahore were currently “under scrutiny”. Interestingly, Al-Sayed was recognised by Punjab HOTA only this May as a transplantation facility.
There was a point when it appeared that Federal HOTA — whose mandate was later limited to the Islamabad Capital Territory — was on the cusp of achieving some real progress in the country’s transplantation programme. During 2013, while it was still engaged in policymaking on a federal level, it laid down the framework for a deceased organ donor programme: this included the development of organ procurement organisations and a national organ sharing network, with the army promising helicopters to fly out organs to wherever needed in the country. Systems were put in place for monitoring transplantation centres through inspection teams to ensure compliance and prevent illegal transplants; and a central database was set up where cases from all around the country could be logged.
Unfortunately, helped along by the administrative disarray that hobbled many government institutions after devolution, HOTA fell prey to corruption and nepotism, the typical afflictions of bureaucracy. Instead of strengthening the deceased organ donation programme that would have addressed the issue of organ shortage that is used by the pro-organ trade lobby to justify preying on people’s desperation, HOTA became a rubber stamp for all manner of irregularities that aided and abetted the organ trade.
In 2014, a three-member official committee was constituted to look into personnel appointments made at HOTA from September 2012 to May 2013 by the Authority’s then administrator Dr Fazle Maula. (The latter was in that post until a few weeks ago.) The committee in its report dated July 3, 2014 concluded two to one in its report, “…that against the 17 sanctioned/vacant posts, 85 persons were illegally recruited and set the worst example of favouritism and nepotism.”
Annexures to the report show multiple recruitments – 14 in some places – on single posts as well as appointees with educational qualifications far short of eligibility criteria. According to a source, “Many of them were personal servants, cooks and security guards of secretaries in the Capital Development Authority. What would they know about transplants, let alone illegal transplants?” Incidentally, Dr Suleman Ahmed, monitoring officer at Federal HOTA is Dr Fazle Maula’s nephew.
The Supreme Court is currently hearing a petition about proliferating illegal transplants in the country. Proceedings have been heated, with allegations flying back and forth.
“It is not true that those who are against the trade in organs disregard people in need of kidney transplants. Such patients have a backup, which is dialysis,” said Dr Mirza Naqi Zafar, general secretary of the Transplantation Society of Pakistan. “There are people who have been on dialysis for over ten years. At the same time, we also need a proper deceased donation programme.”
MNA Kishwar Zehra, who was one of the principal campaigners behind the transplantation law, has introduced an amendment in the National Assembly that would simplify the procedure for deceased organ donation from individuals who lose their lives in vehicle accidents.
As part of her preparatory work for the earlier legislation to regulate transplantation in the country and promote ethical practices, she met scores of kidney donors in villages across Punjab. One incident still brings her to tears. In a village close to Kot Momin, she met a woman who narrated how she sold her kidney in Islamabad. “Did you manage to pay off your debt?” she asked her. “No,” said the woman. “Not yet.” Then she glanced over at her daughter next to her and said: “She’s too young right now. When she’s a few years older, I’ll sell her kidney. Maybe then we’ll be free.”
The names of some donors and recipients have been changed for reasons of privacy.
Further details on dawn.com
Published in Dawn, September 16th, 2016